Questions

Understanding&Treating Cancer Pain

February 26, 2013

Introduction

When you or a loved one receives a cancer diagnosis, it can be an emotional and frightening time. You may think of the pain many people associate with cancer. What will the pain be like? How will it be controlled?

Pain, which can be caused by the disease itself or by treatment (chemotherapy, radiation and surgery), is common in people with cancer. However, not all people with cancer will experience pain. Approximately 30 to 50 percent of people with cancer experience pain while undergoing treatment, and 70 to 90 percent of people with advanced cancer experience pain. Breakthrough pain can also occur in patients who receive treatment in chronic pain.

However, cancer and pain management physicians do offer hope to cancer patients in pain. Opioid medications are the gold standard of pain treatment, but in some patients can cause side effects, including confusion, nausea, vomiting, and constipation. In certain patients, tolerance or addiction (psychological or physical) may occur. To lessen these side effects and improve pain relief, doctors may choose to use more than one pain medication or try different ways to deliver the medicine (for instance, pill, spray, patch or under the tongue). Some patients may benefit from certain anti-depressants to improve mood and help lessen pain.

Opioid use for pain management must always be under the care of a physician. Dosing and changing medications (even the form of medicine and how it is provided) requires a doctor’s order to prevent serious side effects or even death. (Prescribed opioids are responsible for 40 percent of drug fatalities nationally.)

It is important to understand the facts about cancer pain, and learning about the help that is available for pain relief:

Cancer pain can be relieved with pain control in 80 to 90 percent of cases.

Studies show nearly half of those with cancer pain don’t get proper treatment even though much of that pain could be avoided or reduced.

Chronic cancer pain can be successfully treated in about 95 percent of people with drug and non-drug therapies that are currently available.

Physical therapy also can relieve some types of cancer pain. Heat pads, massage and other therapies, like acupuncture, neurostimulation, guided imagery or Reiki may help too.

Unrelieved pain results in sleep disturbances, exhaustion and an inability to work, as well as lead to an increasing feeling of social isolation. Since pain is a subjective experience and only the person who is in pain truly understands its nature, good communication with your health care provider is an essential part of getting adequate pain treatment when you or a loved one has cancer.

For More Information

On Cleveland Clinic Cleveland Clinic Taussig Cancer Institute provides world-class care to patients with cancer and is at the forefront of new and emerging clinical, translational and basic cancer research. At Taussig Cancer Institute, more than 250 highly skilled doctors, nurses and other healthcare professionals provide advanced cancer care to more than 14,000 patients with cancer each year. Clinical trials and internationally known cancer research efforts ensure that patients have access to the latest advances in cancer treatment. A range of support programs are available to help patients navigate the changes and challenges associated with cancer. For more information on Taussig Cancer Institute, cancer conditions, treatments and clinical trials, please visit: my.clevelandclinic.org/cancer/default.aspx For pain management, Cleveland Clinic's Anesthesiology Institute unites all specialists in pain management and anesthesia within one fully integrated model of care to improve diagnosis, medical management and quality of life for our patients. For information on conditions and the latest treatments, please visit: my.clevelandclinic.org/anesthesia/default.aspx

On Your HealthMyChart®: Your Personal Health Connection, is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to: mychartsupport@ccf.org

A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult

For Appointments

To make an appointment with Mellar Davis, MD, or any of the other specialists in our Taussig Cancer Institute at Cleveland Clinic, please call our Cancer Answer Line from 8 am to 5 pm Eastern Standard Time at 216.444.HOPE or call toll-free at 866.223.8100. You can also visit us online at www.clevelandclinic.org/cancer

To make an appointment with Dr. King or any of the other specialists in our Department of Pain Management at Cleveland Clinic, please call 216.444.PAIN (7246) or 800.392.3353. You can also visit us online at www.clevelandclinic.org/painmanagement

About the Speakers

Mellar P. Davis, MD is the Director of the Palliative Medicine Fellowship Program and a staff member of the Solid Tumor Division of Cleveland Clinic’s Taussig Cancer Institute. Dr. Davis is a Professor of Medicine at Cleveland Clinic Lerner College of Medicine, Case Western Reserve University. Dr. Davis completed his fellowship in hematology and oncology at Mayo Clinic, in Rochester, MN in 1983 after his residency in internal medicine at Riverside Methodist Hospital, in Columbus, OH. Dr. Davis graduated from The Ohio State University College of Medicine and Public Health. Dr. Davis special interests include: pain management, cancer pain, palliative medicine, hospice, symptom control, supportive cancer care, cancer related fatigue, cancer anorexia and weight loss, lung cancer, paraproteinemias and amyloidosis.

Ellen King, MD is a staff physician in Cleveland Clinic Department of Pain Management. Dr. King currently sees patients at Cleveland Clinic Main Campus and Twinsburg Family Health & Surgery Center. She completed a fellowship in pain medicine at Hospital of The University of Pennsylvania, in Philadelphia. She completed training in acupuncture at Helms Medical Institute, in Berkeley, CA. Dr. King completed her residency in anesthesiology at Beth Israel Deaconess Medical Center and Harvard Medical School, in Boston, and internship at Metrowest Medical Center, in Framingham, MA, after graduating from University of Iowa College of Medicine. Dr. King’s specialty interests include: cancer pain, interventional pain management, complex regional pain syndrome, neuropathic pain, spinal cord stimulation, chronic back and neck pain, phantom limb pain, arthritis and musculoskeletal pain.

Let’s Chat About: Understanding and Treating Cancer Pain

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialists Dr. Davis and Dr. King. We are thrilled to have them here today to discuss cancer pain. Let's begin with some of the questions that have come in so far.

Analgesic Therapy

lorne: What is the goal of analgesic therapy?Dr_King: The primary goal of analgesic therapy is to find an adequate balance of pain relief with a combination of medications while taking into consideration the safety profile of the medications.

Tellar: What types of pain may be less responsive to analgesics?Dr_Davis: Neuropathic pain (i.e., caused by the nerves) generally requires higher doses of opioids than somatic and visceral pain (i.e., pain from either the outer body or internal organs). Movement-related pain, which we call ‘incident pain’, is difficult to manage because of the rapid onset and peak of pain intensity occurs before oral opioids can relieve pain. Incident pain also tends to be severe. Colicky abdominal pain, bladder spasms, and rectal spasms and pain (called tenesmus, which causes a sensation of always needing to have a bowel movement), as well as headaches, respond poorly to opioids and are better managed by other medicines.Dr_King: Neuropathic pain is very responsive to various neuropathic pain medications, such as membrane stabilizers and serotonin reuptake inhibitors, to name a couple.

you_know: When taking a pain reliever with no relief, even after the second or third one, what should you do about the pain?Dr_King: There might be a variety of reasons why you are not responding to the pain reliever. The pain reliever you are being prescribed may not be appropriate for the type of pain you are experiencing. There might be other treatment modalities that are required to treat your pain.

Pain Assessment

mj4: How do you assess pain, and what is an adequate pain response?Dr_King: There are not many good objective evaluation tools for the assessment of pain. In general practice, pain is assessed by a patient’s report. We consider the patient's reported pain level along with the patient's functionality. An adequate pain response is not necessarily a drop in the level of reported pain, but a combination of increased function and quality of life—even if the pain score remains unchanged.

Severity of Pain and Cancer Survival

calinda: Does having pain that is severe shorten my survival?Dr_Davis: No, there is no association between the presence of pain or severity of pain and cancer survival. However, many people who are experiencing pain are reminded about their cancer or its advancing stage by their pain.

Opioid Therapy for Cancer Pain Relief

Lillian: I am just starting to take opioids for cancer pain. What can I expect? What should I watch for to determine if it is working or not working?Dr_Davis: Hopefully, patients who are started on an opioid will experience a reduction in pain severity, will be more functional, and better able to sleep. There are some side effects which will resolve after a period of days. These include mild muddled thinking and mild nausea. Nausea occurs in a minority of patients, but some individuals will need medicine for nausea on a temporary basis. Constipation occurs in the great majority of patients (at least 80 percent). All of these patients (except for a few) will need to be on laxatives and/or stool softeners. It is probably best not to drive until the dose of opioid has been at a stable level—usually over two weeks. Most people will be able to drive when they are on an opioid. However, some should be tested for their driving ability before driving while on an opioid .

tinaf: When do you change opioids?Dr_Davis: Eighty percent of patients will respond to the first opioid used. However, some may experience intolerable confusion, sedation, nightmares or hallucinations, and/or nausea or vomiting, which limit the ability to increase doses and relieve the pain. At that point we switch to another opioid, change routes of administration of the medication, or add adjuvant analgesics (i.e., other medications that improve the pain relief of the opioid), which may improve pain and allow the opioid dose to be reduced.

Opioid Dose

in_the_air: Is there any relationship between the opioid dose and survival?Dr_Davis: No, each individual has their own minimally important dose that relieves their pain. It can vary as much as a thousandfold. This is largely related to individual differences in response to a particular analgesic.

grand: What are the usual doses of opioids used to relieve pain in cancer?Dr_Davis: Usual opioid doses in terms of milligrams of morphine average between 80 and 120 mg. Ninety percent of patients will need less than 300 mg of morphine daily.

Opioid Therapy and Addiction

1984: What are the chances of becoming addicted if my physician gives me an opioid? Are there any opioids that are safer than morphine? Are there doses that are more at addicting than other doses?Dr_King: All opioid medications have addictive potential. However, if prescribed with proper monitoring and vigilance, the risk of addiction can be reduced. There are multiple opioid formulations that are just as safe as morphine. The important thing to remember is that these medications should be prescribed by a physician who has a good understanding of how to use these medications in a safe manner. There is no particular dose of any medication that is known to be more addictive than another.

Side Effects of Morphine

winters_end: My father is on low-dose morphine for his pain. He is terminal and the pain is expected to get worse. The morphine causes severe constipation. Are there any other medications that you might suggest without this complication? The morphine does take away his pain.Dr_King: Most opioid medications can cause constipation. However, there are other medications and dietary changes that can help to control the constipation. There is a new opioid medication that is supposed to cause less constipation called Nucynta® (tapentadol). However, if morphine is taking away his pain, it is likely best to first try a bowel regimen to combat the constipation.

slavk: This is a very basic question, but regarding the side effect of constipation, how do you decide between a laxative or a stool softener?Dr_Davis: Opioids produce both a hard stool and the reduced ability to have a stool (called defecation). Most individuals need a laxative. Certain individuals who have hard stools or colic will also require a stool softener. Common laxatives are magnesium oxide (commonly called Milk of Magnesia), magnesium citrate, senna, sorbitol, Miralax® (polyethylene glycol), lactulose or bisacodyl. Individuals respond differently to each of those laxatives, and so it is trial-and-error. There are no standard doses for any of the laxatives, and there is a wide difference in response between individuals. Choices should be based on what worked in the past. Individual dose titration (i.e., individualizing the dose to the patient) is necessary as there are no standard doses. In the few clinical trial studies that have been done, there was not an advantage of one laxative over another. About 20 percent of individuals will either need a suppository or an enema. Unfortunately, the bowel never gets used to an opioid, and so laxatives, stool softeners and/or suppositories will need to be taken daily. The goal is to have a bowel movement at least every other day or to come as close as possible to the individual’s normal bowel habit.

Combining Analgesic Medications

todo: Can you combine a prescription pain reliever with over-the-counter pain relievers?Dr_King: You can combine prescription pain reliever with over-the-counter pain relievers. But it is best to consult your treating physician to determine which ones should be used in combination given your specific pain complaints and other medical issues.

update: What about combining analgesics—is it better than using just one?Dr_Davis: Patients who experience multiple pains or a single pain may have multiple mechanisms that generate that particular pain. Therefore, it is not infrequent that opioids alone are inadequate. We frequently use what are called ‘adjuvant analgesics’ to help bring about opioid-induced analgesia (i.e., pain control from the opioids), which may both improve pain and reduce the amount of opioids needed to control pain. By definition, adjuvant analgesics are used for non-pain purposes, such as for the treatment of seizures or depression, but these medications have been found to also reduce pain of a particular kind. The major classes of adjuvant analgesics are antidepressants and antiseizure drugs. There is very little information about combining opioids although it is frequently done. We do not know if combining opioids improves pain control relative to a single opioid used well. There are animal studies to suggest that perhaps in certain circumstances and with certain combinations of opioids, there may be improved analgesia (pain control). However, this should not be routinely done.

Pain from Chemotherapy and Radiation

stormy_weather: Is pain from chemotherapy normal?Dr_Davis: There are several pain syndromes related to chemotherapy. For instance, taxanes can produce acute pain which is responsive to an antidepressant called venlafaxine. There is also acute pain with certain platinum compounds, particularly oxaliplatin, which is significantly dulled by venlafaxine (Effexor®) if started before the oxaliplatin dose. Some people will develop a peripheral neuropathy, which is a burning-like pain in a ‘sock and glove’ distribution. This pain is difficult to manage, but recent evidence suggests that it responds to an antidepressant called duloxetine (Cymbalta®). Some hormone therapies such as aromatase inhibitors can produce pain and may require a change in the medication if severe.

trainer: I had my last chemotherapy treatment about two months ago. My arms, legs and hands frequently cramp up—sometimes severely. It can be very painful. What can be done to help with this?Dr_Davis: Muscle cramps in cancer patients are usually a sign of neuropathy. Do you have numbness and tingling your hands or feet, which would be evidence of chemotherapy induced neurotoxicity? A drug called Cymbalta® (duloxetine) may help if this is a neuropathy related to chemotherapy. A second drug called Lyrica® (pregabalin) has also been found to be effective. It would be important to rule out other causes of cramps such as electrolyte abnormalities including low magnesium. Some women who are iron deficient will get leg cramps at night and may respond to iron. In rare circumstances, cancers that compress the spinal cord may produce a funnel-like pain around an extremity, which can be mistaken for muscle cramps. It’s important that you see a physician about your symptoms, so they can be appropriately diagnosed and treated.

ms_blue: My father is experiencing abdominal pain weeks after completing chemotherapy and radiation. Is this normal and related to the treatment—or is it something else?Dr_Davis: Chemotherapy and radiation adversely affect the bowel. Chemotherapy and radiation cause inflammation as well as shedding of the interior lining of the GI tract. This can produce mucositis or gastroenteritis, commonly causing ‘stomach flu’ symptoms. It can also affect the muscle wall and sometimes the nervous system within the bowel, leading to ‘hypermotility’ of the bowel and diarrhea, or ‘dysmotility’ of the bowel and constipation or even bowel obstruction. There are sensory nerves in the bowel that produce a sensitivity and pain. Fortunately, in most patients this toxicity is temporary and will generally improve in two weeks. Certain chemotherapy agents, such as irinotecan and 5-fluorouracil, may cause diarrhea. If severe, the oncologist should be called and aggressive measures should be taken to avoid secondary complications such as dehydration. Management includes hydration, diet modifications, avoiding milk (which will make the diarrhea worse), and, in severe cases, Sandostatin® (octreotide) injection. There are over-the-counter medications that help with diarrhea (Imodium® and Lomotil®). However, it is important that you notify your physician of the diarrhea to get more specific management. An opioid may worsen colic in this situation. It is also important to rule out other causes of mucositis or diarrhea, such as a herpes infection or clostridium difficile overgrowth. If individuals have an infectious diarrhea, then agents used to stop diarrhea may actually make it worse.

Pain Relief for Bone Metastases

J2K: My mom was put on 10 days of radiation to help her pain from bone metastases. It isn't helping one bit! What else can be done?Dr_Davis: Radiation usually takes four to six weeks to have its full effect. So, patients should not be discouraged if at the end of radiation they don't experience significant pain relief. There are other medications that may help with bone pain. Bone pain has its own particular ‘neuroanatomical signature’, which in part resembles neuropathic pain. There are small nerve endings in the bone which are damaged by cancer. The environment within the bone involved by cancer is acidic, which activates certain receptors. Other chemicals are released such as interleukins, which produce an inflammatory response. Non-steroidal anti-inflammatory drugs such as ibuprofen improve the analgesia (pain-relieving effect) of morphine. Corticosteroids have been used, which may relieve bone pain and improve appetite over the short term. Neurontin® (gabapentin), which has been used for neuropathic pain (like the nerve pain from shingles), also may work for movement-related pain from bone metastases. Bisphosphonates (drugs that are used to help prevent bone loss, such as Fosamax® [alendronic acid] and Boniva® [ibandronic acid]) also reduce complications from bone metastases. However, pain relief is modest, and only occurs after a longer period of use, i.e. months later. Radiofrequency ablation (in which tissue is heated up and destroyed through radiofrequency waves) and, in select cases, bone cement injections have been used for pain relief. This is commonly done for metastases to the spine, which has partially destroyed the bone, using a procedure called kyphoplasty.

Post-mastectomy Pain Syndrome

Janet:My mother has been suffering for years with post-mastectomy pain syndrome. Will she suffer from this pain for the rest of her life?Dr_King: There are a variety of treatments available for treating post-mastectomy pain, including injections to the nerves, acupuncture, manual therapy and medications. Many patients get great pain relief with a combination of therapies.

Complementary Therapies for Cancer Pain Relief

paddy3: What are some of the non-drug approaches to managing pain? Can they be combined with drug management?Dr_King: There are numerous complementary approaches to managing pain besides medications, such as acupuncture, biofeedback and cognitive behavioral feedback. Specially trained pain management physicians can also perform injections for certain types of cancer pain to help reduce or resolve the pain. All of these complementary approaches can be combined with drug management.

carabis: Are acupuncture services offered to Cleveland Clinic cancer patients?Dr_King: We do offer acupuncture services to Cleveland Clinic cancer patients. There are three pain physicians within the Department of Pain Management who are certified in medical acupuncture: Dr. Hong Shen at Lutheran Hospital and Westlake Medical Campus, Dr. William Welches at South Pointe Hospital and Euclid Hospital, and myself at the main campus and soon to be at Twinsburg Family Health and Surgery Center.

Diet and Cancer Pain

sunny_side_up: Can diet affect cancer- related pain?Dr_Davis: There are no known dietary modifications, complementary oral supplements, or particular diets which are known to improve or worsen cancer- related pain. However, there is very little data and few if any studies available that give direction. Your question is an interesting one, but with the present available data, which is meager, there is no evidence.

Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialists Mellar P. Davis, MD and Ellen King, MD is now over. Thank you Doctors for taking the time to answer our questions today about cancer pain.Dr_King: Thank you for joining our web chat today. The physicians in the Department of Pain Management are available to evaluate you and to help you to best manage your cancer pain using a comprehensive approach including medications, interventional pain techniques such as injections, adjunctive therapy such as acupuncture, and psychoemotional support through our pain psychologist.Dr_Davis: Thank you very much it was a pleasure to be with you and to answer questions. If you have additional questions, contact your oncologist or the Cancer Answer Line at 866.223.8100.

Contact Information

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